Since February 2005 I have been treating patients from a biopsychosocial model in which I provide psychotherapy, assessment of the need for psychotropic medication and medication management. As a conditional prescribing psychologist, I am supervised for two years by an Internist who I meet twice monthly for two-hour sessions. At the end of two years, my charts will be reviewed, and then I may apply for an independent prescribing psychologist certificate. It has been a long gestational process and birth to become a conditional prescribing psychologist, but unequivocally it has been worth all the effort.

In order to give you a sense of why I am finding my experience as a conditional prescribing psychologist so worthwhile, let me begin by telling you what I saw when I opened my eyes; in other words, the nature of my patient load since I have been prescribing.

Percent of Weekly Patients

Seeking Medication Management as well as Psychotherapy

As you can see, upon first receiving my prescriptive authority certificate in February 2005, I was responsible for medication management for a very small percentage of my patients. However, in the last two months, I have been involved in medication management for approximately 30%-40% of my patient load. Although I am clearly too ‘young’ at this to make long-term predictions, it is interesting to note that my present prescribing load is very similar to what the Department of Defense Prescribing Psychology graduates have described in their long-term practices, that about 30% of my patients are being treated with psychotropics. An intervening factor that must be considered, however, is that in my relatively small community, many patients and physicians are seeking my services because they know that I am providing both psychotherapy and medication management, and they are looking for that particular specialization. Thus, the nature of the population I am serving seems to be changing.

Table 2 summarizes the characteristics of the twenty-five patients for whom I have been managing psychotropic medication since receiving my conditional prescribing psychologist certificate [click here to see table 2].

One factor of importance, I believe, is that a number of my patients have rather serious concurrent medical conditions. Thus, my initial experiences point to the importance of a prescribing psychologist obtaining extensive training in pathophysiology and treatment of medical disorders.

In my brief life as a prescribing psychologist, I have had a number of opportunities to provide psychotropic care to patients who otherwise had none. For example, patient 2 is a teenage boy for whom I helped determine the diagnosis of Prader Willi broad-spectrum disorder. This patient has classic symptoms of Prader Willi; however, chromosomal testing was inconclusive. His pediatrician and family waited three and half months for an appointment with a child psychiatrist. During their first session, the child psychiatrist saw the young man with his mother for about fifteen minutes. He said that he wanted to request records from the pediatrician and myself before prescribing medication. However, he never followed through. In the meantime, I received my prescribing certificate. In collaboration with the pediatrician, I began prescribing for this patient, and his behavior had improved remarkably. Serious symptoms such as his homicidal threats to others, severe cutting, and inability to get along with peers at school have terminated, and he is evidencing reasonable adjustment at school and at home.

I have also had the opportunity to improve care with patients receiving insufficient care. For example, patient 10 is a young man who was treated for a serious psychotic break subsequent to his drug use. The patient had been hospitalized and was maintained on Zyprexa. However, the side effects of this medication were preventing him from taking a sufficient dose to totally manage his primary symptom of thought broadcasting. His ego alien thoughts about others, that he was sure others could hear, disturbed him greatly. His psychiatrist was in the Midwest, although he had moved to New Mexico, in hopes of attending the University. He was only seeing his psychiatrist every three months for a brief follow-up. From what I could determine, there had been no laboratory tests to assess for possible effects of the psychotropics for over two years. Now that he has been involved in psychotherapy and medication management on a weekly basis with me, the psychotic symptomology is limited to very short time intervals occurring quite infrequently. He feels that he is able to manage these episodes (using psychological techniques such as thought stopping and cognitive behavioral restructuring) and is now holding a job and is back in school.

I believe that becoming a conditional prescribing psychologist has also allowed for more holistic care for many of my patients. Because the patients spend more time with their psychologist than their primary care physician, the psychologist often hears of medical symptoms of which the primary care physician is not aware. As a prescriber in a collaborative relationship with the primary care provider, I maintain frequent and thorough communication with the primary care physician, leading to more effective care of the patient’s medical condition. For example, case 20 in Table 2, who described a “leaded feeling” in his legs. Because the patient described many vegetative symptoms associated with his depression, both he and the PCP assumed that the sensation in his legs was associated with the anergy of his depression. However, as we worked through his depression, the physical symptoms in his legs did not abate. In working closely with the PCP, we discovered it to be a side effect of the medication he was taking for his high cholesterol.

Relatedly, my practice as a conditional prescribing psychologist has broadened the knowledge base for myself as well as the primary care physician. Some have wondered how well the collaborative relationship would work. In my first six months of life with twenty-five patients, I have worked with nine primary care physicians. Some of them, I had known previously; a number I have never met. They have universally been cooperative, sharing results of laboratory tests and accepting my recommendations for intervention. Several have commented that they see a difference in how a psychologist approaches psychopharmacology than other prescribers. Specifically, they are very interested in the more cautious, systematic way we develop a diagnosis. Others have expressed their appreciation that I seem to use a minimum of medication and rely upon less invasive means to assist patients when possible.

One more advantage of being a prescribing psychologist is that it has been a strong motivation for using a best practice model. Our New Mexico prescribing psychologist act and enabling regulations require prescribing psychologists to maintain extensive documentation of our work. In addition, the desire to make certain that a medication is really helping a patient prompts a psychologist to seek very systematic information about our patients before intervening and to seek very objective data about whether our intervention procedures are working. I have developed a number of forms to help me integrate all the data that I need to make a competent diagnosis from a biopsychosocial model and in order to monitor change. (Those forms are available on the internet through the Southwestern Institute for the Advancement of Psychotherapy, of which I am the Training Director. On that website, www.siaprxp.com, there is a link to the practicum handbook, which includes all the forms developed so far). Over these first six months, I have been developing a rhythm of when to talk about the medication, how to move into the psychotherapy session, how to make sure we cover all of the issues of side effects as well as effects of the medication. This rhythm depends upon making sure that the patient is an equal partner in the entire process of psychotherapy and medication management. I think that as we evolve as a specialization, we will work together to systematize the information that we need and the best methods for conducting a biopsychosocial approach to care.

I am growing every day. Quite frankly, there were times those first few weeks where I felt quite awkward at this new skill I am allowed to use. I wondered if I started the medication a little bit too low, and so the patient got frustrated waiting for an effect, or maybe a bit too high, and felt that, had I started lower, side effects would have been less. Perhaps, the most stressful incident was with one of my first patients for whom I prescribed with a diagnosis of Bipolar II, depressive state primary. It seemed to me the most appropriate medication for his diagnosis was Lamictal. Lamictal, as you may know, has a black box warning for a Stevens Johnson’s Syndrome, which is evidenced by a rash. I had looked over the patient’s medical forms, talked about his condition, and the benefits and side effects of the medication. I was ready to hand him a prescription when, once more, we went over the side effects, and I mentioned the importance of his telling me if he had a rash. At that point, he pulled up his pant leg and demonstrated the worst case of psoriasis I have ever seen, which he had not mentioned on the medical forms. Would I be able to separate a Stevens Johnson rash from this psoriasis? I did not risk it. I tore up the prescription, and we started again with a trial of Depakote, which has been quite successful for the patient. Because of a strong therapeutic relationship with the patient, this awkward moment did not have troubling consequences for the therapy process.

There are new challenges to face as a prescriber: insurance carriers that will not pay for the best medication, medications that would be excellent for a condition but are too costly for a patient, and the constant challenge of trying to stay abreast of this vast body of literature and to read through and to separate pharmaceutical advertising from rigorous scientific investigation. Clearly, the authority to prescribe medication really is a privilege, and it is a profound responsibility. It is a privilege because the medications can be of major assistance to our patients; but it is a profound responsibility, also, when a patient puts his or her physical as well as their psychological well being in my hands. For example, I never before had a patient say, that I can remember, that a sentence I told them kept them up all night; but I have had a patient already tell me that with a minute amount of medication, they could not sleep all night. I wonder, was my diagnosis right? Should I stop the medication; decrease it; encourage the patient to try a little longer? Are the side effects too great? I am sure as I have more experience, these questions will be easier to answer, but I do not think that the privilege or the responsibility will diminish.

I have heard some say that prescriptive authority is not rocket science, but I am beginning to wonder. The more I learn of the micro world of the neuron, the complexities of neurotransmission, and how these drugs work, it begins to seem as intricate and as profound as the discussion of quantum mechanics and universes folding in on themselves. It is estimated that there are 100 billion neurons in the brain, as many as there are stars in most galaxies. Each neuron can have as many as 10,000 links to others, making, perhaps, one quadrillion linkages in all. The human brain, its charged impulses, and the thoughts and feelings created are worthy of our most thorough, interdisciplinary care . . . a challenge that psychologists are capable and willing to address.

I am hopeful that, over time, our patients, proponents, as well as those opposed to RxP efforts, will view each prescribing psychologist as filling a valuable, professional niche and will embrace psychology’s professional growth as it enters the arena of primary care, prevention, and treatment.

Return to Top